Provider Demographics
NPI:1508175811
Name:THEOBALD, JOYCE DONNA (MASSAGE TECHNICIAN)
Entity Type:Individual
Prefix:MRS
First Name:JOYCE
Middle Name:DONNA
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MASSAGE TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26900 NEWPORT RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-9224
Mailing Address - Country:US
Mailing Address - Phone:951-672-8060
Mailing Address - Fax:951-672-7490
Practice Address - Street 1:26900 NEWPORT RD STE 110
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-9224
Practice Address - Country:US
Practice Address - Phone:951-672-8060
Practice Address - Fax:951-672-7490
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR-100110017225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist